Provider Demographics
NPI:1649447095
Name:KIM, PHILIP T (DDS)
Entity type:Individual
Prefix:PROF
First Name:PHILIP
Middle Name:T
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9005 CHEVROLET DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-4009
Mailing Address - Country:US
Mailing Address - Phone:410-465-6262
Mailing Address - Fax:410-465-6285
Practice Address - Street 1:9005 CHEVROLET DR
Practice Address - Street 2:SUITE 3
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-4009
Practice Address - Country:US
Practice Address - Phone:410-465-6262
Practice Address - Fax:410-465-6285
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10103122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist